Rejane Sobrino Pinheiro

Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil

O objetivo deste trabalho e analisar o perfil de morbidade referida, acesso e uso de servicos de saude em homens e mulheres no Brasil, segundo idade e regiao urbana e rural. Os dados da PNAD/98 mostram que as diferencas de genero na morbidade variam com a idade: desfavoraveis aos meninos ate os 10 anos e desfavoraveis as mulheres a partir dos 15 anos, aumentando ate os 64 anos e reduzindo apos esta idade. A alta prevalencia de atendimento indica que as barreiras de acesso dos que procuram servicos de saude sao pequenas. No entanto, o elevado percentual de nao procura face as necessidades percebidas sugere que as barreiras de acesso sao anteriores e dependem da oferta. A cobertura por planos de saude e bem maior na regiao urbana, mas nao ha diferencas de genero significantes nas regioes. As diferencas entre homens e mulheres nas taxas de uso curativo sao pequenas, se comparadas com as de uso preventivo, maiores para as mulheres, assim como as taxas de internacao, mesmo excluindo os partos. O financiamento das internacoes nao foi diferente entre homens e mulheres, ao contrario do financiamento de outros tipos de atendimento: maior cobertura por planos para mulheres na regiao urbana; na regiao rural, maior uso do SUS para as mulheres e maior desembolso de recursos proprios para os homens.

Utilização dos serviços de saúde no Brasil: gênero, características familiares e condição social

Estudo financiado pela Organizacao Pan-Americana da Saude atraves do Concurso Regional de Investigacion 1999 sobre “Genero y equidad en el acceso a la atencion de la salud en las reformas de los sistemas de salud y seguridad social”. HDP/HDR/RGP/81/5.3.

Uso de serviços odontológicos entre os Estados do Brasil

O objetivo deste trabalho foi analisar a relacao entre as caracteristicas dos individuos e do contexto no uso de servicos odontologicos no Brasil, e analisar as diferencas entre grupos populacionais nas proporcoes de uso destes servicos entre os anos de 1998 e 2003. Foram analisados os dados da Pesquisa Nacional de Amostras por Domicilios (PNAD) de 2003, a partir de modelo logistico hierarquico das chances de um individuo nunca ter consultado o dentista segundo caracteristicas do individuo e do contexto das unidades da federacao. Foi observado que a chance de nunca ter visitado o dentista foi 20% maior para os homens; maior para os idosos em comparacao com os de 50 a 64 anos; 3,4% menor para os de raca branca; 46,6% menor para os que possuem plano de saude; e 42,9% menor para os que residem em regiao urbana. Para cada ano a mais de estudo, a chance foi 17% menor. Comparando com os 20% mais pobres, a chance de nunca ter consultado o dentista foi 27,1% menor para os individuos do segundo quintil de renda familiar per capita e 74,1% menor para os 20% mais ricos. Variaveis contextuais mostraram associacao com o uso de servicos odontologicos que foi menor entre as unidades da federacao mais pobres, com menor estrutura, com menor oferta de servicos odontologicos, medicos e servicos de saude de maior complexidade.

Estudo da desigualdade na utilização de serviços de saúde por idosos em três regiões da cidade do Rio de Janeiro

This article analyzes social inequalities in health care services utilization by the elderly and tests the influence of place of residence. The study was based on a sample survey of residents 60 years of age and older from three different areas in the city of Rio de Janeiro. The multi-stage sampling method led to violations of the logistic regression assumptions which were considered in the data analysis stage. Need was the most important factor related to utilization. However, gender, type of service, income, and place of residence also showed positive impact on health care utilization. Moreover, the effect of the income was modified by place of residence. The area with the best living conditions (Copacabana) did not show inequalities in health care services utilization. The income gradient was more important in middle and lower-income areas, i.e., Meier and Santa Cruz, respectively.Neste trabalho, foi analisada a desigualdade social na utilizacao de servicos de saude e a influencia que a area de residencia exerce nessas desigualdades. Com informacoes baseadas em um questionario multidimensional aplicado a uma amostra de idosos da cidade do Rio de Janeiro, foi estudada a associacao do uso de servicos de saude com fatores socio-demograficos, condicao social, necessidade e oferta de servicos medicos. O desenho amostral complexo levou a violacoes de pressupostos do modelo de regressao logistica, que foram tratadas na fase de analise dos dados, com base no calculo do efeito do desenho. O fator mais importante na explicacao da variacao no uso de servicos de saude por idosos foi necessidade. Porem, ser do sexo feminino, renda, area de moradia e ter direito de usar servico privado tambem mostraram efeito positivo no consumo de servicos de saude. O modelo apontou ainda para a existencia de interacao entre area de residencia e renda. A area de alto padrao de vida, representada neste estudo por Copacabana, nao apresentou desigualdades internas no uso de servicos de saude, sendo o efeito da renda mais importante em locais classificados em niveis de padrao de vida medio e menor (Meier e Santa Cruz, respectivamente).

Condicionantes socioeconômicos e geográficos do acesso à mamografia no Brasil, 2003-2008

This study examined the effect of population characteristics and geographic location of residences and services on the odds of receiving a mammography in 2003 and 2008. Patterns of mammography use were analyzed using data from the Health Supplements of the National Household Sample Survey for women aged over 25, using prevalence ratios, and for women over 40 using multivariate logistic regression, correcting for complex sample design effects. In 2003, 54.6% of women of 50-69 years of age reported having had a mammography, in 2008, 71.5%. The odds are higher for those 50 to 69 years old, and increase with family income, education, being married, having consulted a doctor and having health insurance. Living in a metropolitan area trebles the chance of mammography. Compared to the Northern region, residents in all other regions have greater odds, greater distances decrease the odds. Coverage increased in the age range targeted by national policy, and inequalities due to income and education on access to mammography were reduced but regional convergence was not marked. Increased access seems to relate more to policies of income distribution and social inclusion, and to the availability of the examination in the Unified Health System, than to an increasing number of mammography units.

Acesso à assistência oncológica: mapeamento dos fluxos origem-destino das internações e dos atendimentos ambulatoriais. O caso do câncer de mama

This study analyzes the flow of patients with breast cancer treated in Brazils Unified National Health System (SUS) by type of treatment (surgery, radiotherapy, and chemotherapy). Hospital and outpatient services networks were identified based on data from the National Information System for Inpatient Care (SIH), and the National Information System for Outpatient Cancer Care, for 2005-2006, using TabWin and TerraView. Health services networks reach most of the country, and few municipalities are not connected to a network. However, treatment is highly concentrated in the largest cities, and even the latter show evidence of service shortages. Furthermore, a large proportion of patients live more than 150km from the respective service. Network identification is important for planning and improving services distribution, since geographic access is a relevant issue for treatment outcome. Reduction of morbidity and mortality requires early identification, and appropriate and prompt treatment can reduce the impacts of the disease.

Uso do sistema de informação sobre mortalidade para identificar subnotificação de casos de tuberculose no Brasil

The aim of the study was to analyze the underreporting of deaths from tuberculosis (TB) in Brazil, as well as to assess the impact these cases would cause in the reporting rate and proportion of TB deaths in 2006. We analyzed the deaths recorded in the Mortality Information System (SIM) in 2006 and all reports of TB in Brazil during the 2001 to 2006 period. The variables used for the relationship were: report number, city and State of residence, patient name, date and year of birth, sex, mothers name and address. Six blocking steps were performed. Scores above 12.4 were considered pairs, and those below 9.7, doubtful pairs. After each step, we performed a manual review of doubtful pairs. The Reportable Disease Information System (Sinan) had 547,589 records. The SIM had 6,924 records, 39.3% (n = 2,727) of which were not found in Sinan during the period evaluated. We observed that 64.5% (2,707) of deaths were reported in 2006 and after analyzing the proportion of deaths underreported by region and federal units, we found that the highest percentage was in the Northern region, followed by the Southeast and Northeast. The addition of deaths that had not been reported to the Sinan database increased the reporting rate 3.7%. Regarding the proportion of deaths due to TB, such inclusion was responsible for a 60.7% increase in this indicator. The relationship between both databases seems to be an important strategy for improving the quality of the TB surveillance system.

Modifying Effect of Prenatal Care on the Association Between Young Maternal Age and Adverse Birth Outcomes

OBJECTIVES The objectives were to investigate the prevalence of adverse birth outcomes according to maternal age range in the city of Rio de Janeiro, Brazil, in 2002, and to evaluate the association between maternal age range and adverse birth outcomes using additive interaction to determine whether adequate prenatal care can attenuate the harmful effect of young age on pregnancy outcomes. METHODS A cross-sectional analysis was performed in women up to 24 years of age who gave birth to live children in 2002 in the city of Rio de Janeiro. To evaluate adverse outcomes, the exposure variable was maternal age range, and the outcome variables were very preterm birth, low birth weight, prematurity, and low 5-minute Apgar score. The presence of interaction was investigated with the composite variable maternal age plus prenatal care. The proportions and respective 95% confidence intervals were calculated for adequate schooling, delivery in a public maternity hospital, and adequate prenatal care, and the outcomes according to maternal age range. The chi-square test was used. The association between age range and birth outcomes was evaluated with logistic models adjusted for schooling and type of hospital for each prenatal stratum and outcome. Attributable proportion was calculated in order to measure additive interaction. RESULTS Of the 40,111 live births in the sample, 1.9% corresponded to children of mothers from 10-14 years of age, 38% from 15-19 years, and 59.9% from 20-24 years. An association between maternal age and adverse outcomes was observed only in adolescent mothers with inadequate prenatal care, and significant additive interaction was observed between prenatal care and maternal age for all the outcomes. CONCLUSION Adolescent mothers and their newborns are exposed to greater risk of adverse outcomes when prenatal care fails to comply with current guidelines.

Óbitos e internações por tuberculose não notificados no município do Rio de Janeiro

OBJECTIVE To analyze underreporting of deaths and hospital admissions from tuberculosis to the Information System for Notifiable Diseases (SINAN). METHODS Cases with tuberculosis as basic or associated cause of death were selected from the Brazilian Mortality Information System (SIM) and hospital admissions for tuberculosis as main or secondary cause from the Hospital Information System of the Brazilian Unified Health System (SIH-SUS), for residents in the municipality of Rio de Janeiro in 2004. Probabilistic record linkage was carried out between the SIM and SIH-SUS databases and the SINAN for the years 2002 to 2004. RESULTS Out of the 542 deaths from tuberculosis in the period, 234 (43.2%) were not registered in the SINAN for the two previous years. As for the 1,079 admissions, 238 (22.1%) failed to be notified. Seventy-one deaths were related to these admissions: 47 were registered out of the SIH-SUS by death, 24 occurred after discharge and seven remained unnotified in the SINAN. The elderly were 1.6 times (95%CI 1.074;2.516) less likely to be notified than younger patients, and those with at least a college education were 3.6 times (95%CI 1.384;11.022) less likely to be notified than those with no formal education. Patients under 15 were 4.8 times (95%CI 2.757;8.452) less likely to be notified than those aged between 15 and 59 years. Some regional health administration divisions showed a percentage of unnotified deaths of over 50% and this percentage ranged from 37.8% to 12.7% for hospital admissions. CONCLUSIONS The data suggest problems in the detection of cases and point to obstacles in adequate and timely treatment, as well as to quality flaws in the information system, with differences among regions in the municipality.OBJETIVO: Analizar la subnotificacion de obitos e internaciones por tuberculosis en el Sistema de Informacion de Agravios de Notificacion (Sinan). METODOS: Se seleccionaron los obitos del Sistema de Informacion sobre Mortalidad (SIM) con causa basica o asociada a tuberculosis y las internaciones del Sistema de Informaciones Hospitalarias del Sistema Unico de Salud con causa principal o secundaria tuberculosis de residentes en el municipio de Rio de Janeiro (Sureste de Brasil) en 2004. Se realizo asociacion probabilistica de las bases de datos del SIM y SIH-SUS con la del Sinan, referentes a los anos de 2002 a 2004. RESULTADOS: De los 542 obitos por tuberculosis en el periodo, 234 (43,2%) no fueron registrados en el Sinan en los dos anos anteriores. De las 1.079 internaciones, 238 (22,1%) no fueron notificadas. Se relacionaron a las internaciones 71 obitos: 47 durante la internacion por tuberculosis, 24 posterior a la internacion. Siete no fueron notificados en el Sinan. Los ancianos presentaron 1,6 veces (IC 95% 1,074;2,516) la probabilidad de no notificacion con relacion a los mas jovenes, y personas con nivel superior o mas de escolaridad presentaron 3,6 veces la probabilidad (IC 95% 1,384;11,022) de no ser notificados con relacion a los que no tenian ningun ano de estudio. Los menores de 15 anos reflejaron 4,8 veces la probabilidad (IC 95% 2,757;8,452) de no notificacion con respecto a los que tenian de 15 a 59 anos. Algunas divisiones regionales de salud presentaron porcentaje de obitos no notificados por encima del 50% y ese porcentaje vario entre 37,8% a 12,7% para internaciones. CONCLUSIONES: Los datos sugieren problemas en la deteccion de casos y apuntan barreras de acceso al tratamiento oportuno y adecuado y fallas en la calidad del sistema de informacion, con diferencias entre las regiones del municipio.OBJETIVO: Analisar a subnotificacao de obitos e internacoes por tuberculose no Sistema de Informacao de Agravos de Notificacao (Sinan). METODOS: Foram selecionados os obitos do Sistema de Informacao sobre Mortalidade (SIM) com tuberculose como causa basica ou associada e as internacoes do Sistema de Informacoes Hospitalares do Sistema Unico de Saude (SIH/SUS) com causa principal ou secundaria tuberculose de residentes no municipio do Rio de Janeiro em 2004. Foi realizada associacao probabilistica das bases de dados do SIM e SIH-SUS com a do Sinan, referentes aos anos de 2002 a 2004. RESULTADOS: Dos 542 obitos por tuberculose no periodo, 234 (43,2%) nao foram registrados no Sinan nos dois anos anteriores. Das 1.079 internacoes, 238 (22,1%) nao foram notificadas. Foram relacionados as internacoes 71 obitos: 47 ocorreram durante a internacao por tuberculose, 24 apos a internacao. Sete nao foram notificados no Sinan. Os idosos tiveram 1,6 vez (IC95% 1,074;2,516) a chance de nao notificacao dos mais jovens, e pessoas com nivel superior ou mais escolaridade tiveram 3,6 vezes a chance (IC95% 1,384;11,022) daqueles com nenhum ano de estudo de nao serem notificadas. Os menores de 15 anos tiveram 4,8 vezes a chance (IC95% 2,757;8,452) de nao notificacao daqueles entre 15 e 59 anos. Algumas divisoes regionais de saude apresentaram percentual de obitos nao notificados acima de 50% e esse percentual variou entre 37,8% e 12,7% para internacoes. CONCLUSOES: Os dados sugerem problemas na deteccao de casos e apontam barreiras de acesso ao tratamento oportuno e adequado e falhas na qualidade do sistema de informacao, com diferencas entre as regioes do municipio.

Subnotificação da tuberculose no Sistema de Informação de Agravos de Notificação (SINAN): abandono primário de bacilíferos e captação de casos em outras fontes de informação usando linkage probabilístico

This study aimed to analyze underreporting of tuberculosis (TB) cases in the Information System on Notifiable Diseases (SINAN), based on the following data sources: Mortality Information System (SIM), Registry and Follow-up Book for TB Case Treatment (LPATB), and Laboratory Registry Book (LRLAB). Probabilistic record linkage was used between the SIM (2007-2008) and SINAN (2002-2008). A search was conducted in LPATB and LRLAB (2007-2008) for cases not recorded in SINAN. There were 125 deaths, of which 44.8% were not recorded in SINAN. In LPATB, 58 cases (5.1%) were in treatment and were not reported in SINAN. LRLAB showed 32 smear-positive cases not reported to SINAN and without treatment, representing primary default. Addition of the retrieved cases, led to a 14.6% increase in the incidence rate in 2007 and 11.6% in 2008. Underreporting of deaths from or with TB in the Mortality Information System and primary default revealed difficulties in access to adequate and timely treatment, calling for rethinking of strategies to detect cases for timely treatment.